Investigation and Clinical Application Approach to Anemia (L3) PDF

Investigation and Clinical application approach to anemia L.3 Prof. Waseem AlTameemi  Learning objectives L ✓To list indications of BM & to differentiate 3, W aspiration from Bx. a s e ✓To apply flow cytometry in clinical in...

Investigation and Clinical application approach to anemia L.3 Prof. Waseem AlTameemi  Learning objectives L ✓To list indications of BM & to differentiate 3, W aspiration from Bx. a s e ✓To apply flow cytometry in clinical indications e m ✓To define history approach in anemic T a patient. m e e ✓To classify anemia according to RBC m i indices To recognize iron metabolism and distribution in the body 2/3/2024 2  BM examination !‫بيه نوع‬ aspirate ‫واحد‬ biopsy ‫والثاني‬ L 3 , W a s e e m T a m e e m i 2/3/2024 3  Sites of biopsy: BM examination - posterior superior iliac spine (iliac crest) -anterior superior iliac spine -tibial tubrosity ( for aspiration only ) (in children) -sternal aspirate L 3 , W a s e e m T a m e e m i 2/3/2024 4  ‫يد‬.‫اختصاراً لهاي الس‬ Bone marrow aspiration and aspiration ‫اني عندي ال‬ :‫ت منها‬.‫يفيدني بهواي شغ‬ -Morphology of cells biopsy Bone marrow aspirate is to take marrow materials -count of cells By syringe to look for cell morphology , composition of -any infiltration of BM the cells in BM , enumerate myeloid erythroid ratio. -for cytogenetic analysis L 3 Aspirate of BM cells: Myeloid -erythroid ratio ‫بيض‬4-6:1 Normally and karyotyping -for cultures , for composition cell ‫ياه هي كريات دم‬.‫النخاع اغلب خ‬ (agranulocytes) W criteria (M:E, ‫مر‬9‫يا ا‬.:‫وبيه كميه فليله من ا‬ a ‫ يبينلك كل خليه دم حمره يقابلها‬ratio‫ف هذا ال‬ s e morphology ,number ‫يا بيض داخل النخاع‬.‫ خ‬٦ ‫ الى‬٤ ‫من‬ e ,infiltrate of marrow ) m cytogenetic, T immunophenotypic (CD) CD marker for each ce$ a and molecular m (karyotype and NGS) Next generation Sequencing to identify e analyses (any mutated any mutations in genes e m gene). i Cluture For tuberculosis PUO Kala-azar Bruce$osis 2/3/2024 5  Bone marrow aspiration and biopsy L 3 , Trephine biopsy of bone W a (cortex & medulla): Hypoce$ular s e for degree of cellularity & Hyperce$ular e m fibrosis , infiltration, T tissue histology & a m infection In case of TB e e Superior than aspirate in m i AA , MF and metastasis Aplastic anemia Myelofibrosis 2/3/2024 6  Indications of bone marrow ‫مهم‬ examination L 3 1. Diagnosis cytopenia: 4. Unexplained splenomegaly , 1. Pancytopenia W a 5. Diagnosis of Infection: PUO, 2. AAAplastic anemia s 3. Megaloblastic anemia TB, kala-azar e e 4. MDSMyelodysplastic anemia 6. Diagnosis storage disease m 5. BM metastasis (Gaucher disease) storages It is the best to assess the but it is invasive so, it's not suitable for a$ T 6. BM fibrosis patients. a 7. Assessment of Iron storage m 2. Diagnosis leukemia , sideroblastic anemia e Multiple myeloma 8. Monitor of disease response e and Measurable MRD residual disease ‫صار زين‬ ‫ريض‬7‫هذا في حال ا‬ ‫واختفت عليه كل ا=عراض‬ m i 3. Diagnosis and Staging of ‫ يختفي هو و‬spleen ‫وحتى ال‬ lymph nodes ‫ال‬ lymphoma ‫ف نروح نوديه ع‬ ‫ علمود اشوف‬aspiration mutation in ‫هل عنده‬ ‫? ف ممكن ب‬genes ‫ستقبل‬7‫ا‬ ‫رض‬7‫يرجعله ا‬ ‫حتلو تعالج‬ 2/3/2024 7  BM examination genera$y is safe but can cause: CONTRAINDICATIONS ‫مهم‬ Hemorrhage Pain Infection Hemophilia, L 3, Severe disseminated intravascular coagulopathy.Correct then do aspiration W a s e ‫مهمه‬ Thrombocytopenia, is not a contraindication e m T a m e e m ADVERSE EFFECTS; none significant i 2/3/2024 8  The “dry tap” ce$ular material‫ ونسحب بس ما يجينه‬syringe ‫نحط ال‬ ‫مهم‬ L no material will be aspirated. Causes: 3, W 1. technical: needle is not pass the cortex Superficial a s e 2. fibrosis of the marrow (MF) ce$ular materials ‫ فماكو‬fibrosis ‫ صاير بيه‬BM ‫=ن كل ال‬ e m 3. Hairy cell leukemia T a 4. BM Metastasis (myelophthesis) m e e 5. Acute leukemias (blast cells impaction in m i marrow) 6. Mailiary TB 2/3/2024 9  When is the biopsy most useful? Myelodysplastic syndrome L 3, 1. Aplastic anemia, MDS,MF. Myelofibrosis Biopsy is useful more than aspiration in these cases bcz of blast ce$s W a s 2. Metastatic carcinoma e e 3. Lymphoma staging aspirate ‫ ب ال‬normal ‫تطلع‬ m T a 4. Suspected granulomatous disease (PUO) m e 5. Dry tap aspirate e m i biopsy ‫ وبعدها ادز ع‬aspirate ‫اغلب الحا=ت ناخذ ب البدايه‬ ‫ بس‬aspirate ‫ ندزه ع‬acute leukemia ‫بس في حال‬ 2/3/2024 10  Flow cytometry ‫ل‬e‫هذا جهاز بيه ضوه ليزر يمر خ‬ physical‫يا حتى يوضحلي ال‬e‫الخ‬ :٣ ‫يا والي هن‬e‫ للخ‬characteristics L 3 , W a laser light source of ce$s -ce$ size -ce$ularity -antigenic characteristics a s e to measure the e m physical or antigenic T a characteristics of cells m e e Based on the intensity m i of scattered light 2/3/2024 11  Flow cytometry L cell size and granularity, 3 , W nuclear complexity, a s surface antigens, and e e cytoplasmic antigens m T a m e e For Granularity m i For ce$ size 2/3/2024 12  Flow Cytometry Applications L ‫حتى نحدد نوعها‬ 3 , 1) Diagnosis and classification : W a Leukemia and lymphoma s immunophenotyping e e m 2) Diagnosis of immunodeficiency disorders: CD4 useful in case of HIV -AIDS When the CD count number less than 200 T Treatment a m 3) Monitoring response to Tx and e Prognosis(MRD) e m i 4) Transplantation: Stem cell enumeration ‫حتى نحسب كم خليه‬ !‫محتاج‬ 2/3/2024 13  ANEMIA Reduced RBC count -->less o2 transferred to tissues-->hypoxia. ‫حفظ ا=رقام‬ L 3, W Neonate 13.0 a s e e m T a m e e m i 2/3/2024 14  History Approach Anemia could be asymptomatic L 3, Onset, duration; acute ,chronic. W a Blood loss; GIT, menstruation. s e Jaundice Hemolytic Symptoms depend on the rapidity of development e m Bleeding , infection Acute onset anemia give more manifestations than T a Dietary history Vegetarian pt. -B12 deficiency the long standing anemia m e Family history Thalassemia, G6PD, hereditary spherocytosis Most imp. Type of anemia is iron deficiency anemia Drug ,alcohol And the most common e mechanism is through blood loss m Heamorrhoid Age i Gender Most imp. System involed Variable Clinical presentation Onset Co morbid is Elementary system(GIT) in men and post-menopausal women state But in child bearing women it's 2/3/2024 imp. To ask about menstural history 15  ‫هذا مهم‬ L 3, W a Pathophysiology s and manifestation e e m T a m e e m i Can cause heart failure 2/3/2024 16  Classification of anemia (based L on MCV) Mean corpuscular volume 3 , W A. Microcytic anemia if MCV< 76fl a s Defect in Hb synthesis: e e I. (IDA) Iron Deficiency Anemia m II. (hemoglobinpoathy)Thalassemia trait T a III. ( ACD) anemia of chronic disease Anemia of inflammation m e (but only 20% of cases) e m IV. Congenital sideroblastic anemia.Defect in heam ring i V. lead poisoning ً ‫مهم جدا‬ Only 20% of cases presented with microcytosis due to poor iron 2/3/2024 utilization 17  Classification of anemia (based L on MCV) 3 , B. Macrocytic anemia if MCV>100 fl W a I. Defect in DNA synthesis: s Deficiency (B12, folate) e e MDS, drugs (cytotoxic)Hydroxyurea m II. Others: T a Hemolytic anemia m Aplastic anemia e e liver disease and Alcohol m i Hypothyroidism 2/3/2024 18  Classification of anemia (based on MCV) L 3 , C. Normocytic anemia :Classical disease type of anemia of chronic W a MCV 76-100 fl s e secondary anemia (ACD)in renal failure, e m rheumatoid arthritis (80%of cases) Normocytic T Microcytic Macrocytic a m e Acute blood loss -IDA -ACD -hemoglobinopathy -B12, folate deficiency -MDS -Cytoxic drugs -renal failure -rheumatoid arthritis e -sideroblastic anemia -hemolytic anemia -acute blood loss m -Lead poisoning -liver disease -alcohol i -hypothyroidism 2/3/2024 ‫مراجعه‬ 19  Classification of anemia (based on reticulocyte) L 3 , Reticulocyte count: W a Erythropoiesis of BM s I.Reticulocytosis: High BM activity II.Reticulocytopenia:Low BM activity e e 1) hemolysis(acute,chronic) 1) suppressed bone m marrow, T 2) acute bleeding a 2) in aplastic m 3) following hematinics anemia,megaloblastic e anemia, following When the count more than 100,000 e Or more than 2% m i chemotherapy 2/3/2024 20  Classification of anemia (based on RDW) L 3 RDW: , W a it is a measure of variation in RBC volume. s e e Red ce$ distribution width m High RDW : in microcytic anemia ; indicates T heterogeneous population of RBC in IDA. MCQ a m e Normal RDW : in microcytic anemia ; indicates e homogenous population of RBC in Thalassemia trait. m Case1 A55 year old women referred to hematologist bcz of the anemia i with these automated blood count RBC count -- 2 mi$ion ⬇ Hemoglobin--7 ‫لزمه بس ذكرها‬7‫هذي كيس ما موجوده ب ا‬ PCV--22 Q1/Name of anemia ? Microcytic anemia MCV--70 Q2/what are the causes?‫ذكرناها فوگ‬ 2/3/2024 MCH--26 RDW is elevated so its IDA MCHC--28 RDW--20 21  Case 2 55 year old women with history of gastrectomy referred to hematologists bcz of anemia. Iron Deficiency Anemia (IDA) RBC--2 mi$ion ⬇ Hb--7⬇ Q1/name of anemia ? Macrocytic anemia PCV--10⬇ Q2/what are the possible causes? MCV--126⬆ ‫ هي مسويه‬gastrectomy + ‫ذكرناهن فوگ‬ RDW--20⬆ L 3, W World wide health problem (30%) a s e Variable prevalence with age, sex, e m economic status T a m Infancy, preschool children, menstruating e e m &pregnant women (10%) i Adult men (1%) Pathological 2/3/2024 22  Iron Metabolism L 3 , Present in environment The body can W ,but (inactive) Ferric state increases iron a absorption if there is s e In body, it is active soluble increased demand e m ferrous iron pregnancy, lactation, Under control of intestinal growth spurts, and iron T deficiency. a m absorption e No excretion of iron e m No active physiological i Absorption : 10%of daily mechanism of excretion dietary content ‫ على حسب احتياج جسمك اليومي‬، = ‫مو كل الي حتاكله حيتم امتصاصه‬ 2/3/2024 23  Iron distribution in body L 3 1. Functional: , W 2. Storage: ‫حفظ صيغ خزن‬ a ‫الحديد وتعرف وين‬ s ‫اكثر شي متركز‬ e 1g in males e m 300 mg in females T Until menopause a m e e m One pint blood= i 200 mg iron ‫حفظ‬ 2/3/2024 24  Iron Absorption Absorbed in the brush border of the Rice upper small intestine Duodenum and jejunum Spinach Black beans Enhanced by gastric acid Corn Inhibited by tannins, systemic Lettuce inflammation Wheat Soy beans Ferritin Most dietary iron is nonheme form, liver 25% bioavailability 0 5 10 15 20 25 Iron Absorption (% of dose)  Iron Absorption L ‫مهم‬ 3 , W a s e 10-15 mg \day e m (10% of dietary iron)= 1-1.5 mg/day T a xxx3 m e e m i 2/3/2024 26  ‫كلها ذكرناها فوگ‬ Iron Absorption L 3 Absorption enhanced  Absorption , W by reduced by a I. Diet: s I. Diet: e e II. Luminal :acidic Ph, m vitamin, AA. II. Luminal: alkali, phytate, T tannate, calcium. a drugs (tetracyclin, m e ciprofloxacin) e III. Systemic: IDA, m bleeding, pregnancy, III.Systemic: iron i hypoxia. overload, inflammation 2/3/2024 27  Iron absorption From liver L 3, Hepcidin : Hepcidin is the negative factor W a s controls absorption and storage e e inhibits iron transfer from duodenal cells m T and macrophages , a m e Increased by inflammation, suppressed e m in IDA i 2/3/2024 28  Iron Transport L 3  Transferrin ; From liver , W iron transport protein ‫بروت! ناقل للحديد ب الدم‬ a ‫هذا تيست‬ s TIBC= transferrin Total iron binding capacity ‫نستخدمه حتى‬ e ‫نحسب ال‬ transferrin e Inverse relation ship with iron stores (transferrin m ‫قليل والعكس صحيح‬tibc ‫كلما الفرت! عالي كلما ال‬ level) T a  TS(transferrin saturation) : Normally , it is 33%saturated m TS =Serum iron/TIBC e with iron. e m  Serum transferrin receptor protein (TfR) : guide for i erythrpoiesis activity , differentiation IDA from ACD 2/3/2024 29 Students questions  SUMMARY Value and interpretation of BM examination and FC. Definition and prevalence of anemia Definition ,Principles of Classification of Anemia. Thank you